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    NC FARHAN RESPI Salinan

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    Rima Khairunnisa
    1) This document summarizes a clinical conference discussing a 1-year-old male patient admitted with shortness of breath, cough, and anemia. 2) The patient's working diagnoses were community-acquired pneumonia, acute tonsillopharyngitis, stunting, delayed immunization, and iron deficiency anemia or anemia of chronic disease. 3) The patient's treatment plan included oxygen, intravenous antibiotics, paracetamol for fever, and nebulization with saline. Further testing and consultations were also planned.

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    NC FARHAN RESPI Salinan

    Uploaded by

    Rima Khairunnisa
    18 views21 pages
    1) This document summarizes a clinical conference discussing a 1-year-old male patient admitted with shortness of breath, cough, and anemia. 2) The patient's working diagnoses were community-acquired pneumonia, acute tonsillopharyngitis, stunting, delayed immunization, and iron deficiency anemia or anemia of chronic disease. 3) The patient's treatment plan included oxygen, intravenous antibiotics, paracetamol for fever, and nebulization with saline. Further testing and consultations were also planned.

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    NC FARHAN RESPI salinan

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    1) This document summarizes a clinical conference discussing a 1-year-old male patient admitted with shortness of breath, cough, and anemia. 2) The patient's working diagnoses were community-acquired pneumonia, acute tonsillopharyngitis, stunting, delayed immunization, and iron deficiency anemia or anemia of chronic disease. 3) The patient's treatment plan included oxygen, intravenous antibiotics, paracetamol for fever, and nebulization with saline. Further testing and consultations were also planned.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
    Download as pptx, pdf, or txt
    18 views21 pages

    NC FARHAN RESPI Salinan

    Uploaded by

    Rima Khairunnisa
    1) This document summarizes a clinical conference discussing a 1-year-old male patient admitted with shortness of breath, cough, and anemia. 2) The patient's working diagnoses were community-acquired pneumonia, acute tonsillopharyngitis, stunting, delayed immunization, and iron deficiency anemia or anemia of chronic disease. 3) The patient's treatment plan included oxygen, intravenous antibiotics, paracetamol for fever, and nebulization with saline. Further testing and consultations were also planned.

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    © All Rights Reserved
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    of 21

    CLINICAL CONFERENCE

    RESPIROLOGY DIVISION
    (New Case)
    July 4th , 2023
    IKA KURNIA FAIZIN, AYU JAURY, TRI WIRA/ JUNIOR
    RIMA KHAIRUNNISA, CAHYA KAMILA BAUSAT, SITI SOPIA / MADYA
    MUHAMMAD MUSTAQIBLAT, DIAN JABAL RACHMAN BEY, IRFADAH DINAR / SENIOR
    PATIENT IDENTITY
    FF, 1-Year-and-15-day-old, male
    MR Number 01029276
    Date of Birth May 01th , 2022
    Admission Date June 19th , 2023
    MEDICAL DIAGNOSIS
    COMMUNITY-ACQUIRED PNEUMONIA
    ACUTE TONSILLOPHARYNGITIS
    ANEMIA OF CHRONIC DISEASE DIFFERENTIAL DIAGNOSE WITH
    IRON DEFICIENCY ANEMIA
    LEUCOCYTOSIS
    ELEVATED TRANSAMINASE ENZYME
    REACTIVE THROMBOCYTOSIS
    STUNTING
    PATIENT PICTURE
    HISTORY TAKING
    Chief complaint:
    Shortness of breath

    History of Present Illness


    • A 1-Year-old boy was referred from pediatrician with diagnosis of anemia pro evaluation with
    leucocytosis.There was shortness of breath experienced since 3 days prior admission and got worsening 1
    day before admission. There was productive cough since 1 week before admitted to the hospital. No fever,
    there was history of fever since 1 week before admitted to the hospital, not continuous, reduce with
    antypiretic drugs. No seizure (1 seizure history, duration <5 minutes, the patien crying when the seizure
    stop).
    • No vomiting.
    • Oral intake normal.
    • Urination and defecation within normal limit
    HISTORY TAKING
    There was no history of fever > 2 weeks.
    There was history of cough > 3 weeks
    No history of contact with TB-confirmed patient or with chronic cough
    No family history of smoking
    There was history of seizure on June 2023
    There was history of hospitalization at B hospital on June 2023, diagnosed with febrile seizure
    and acute pharyngitis
    There was history of previous treatment with a pediatrician and got therapy: Isprinol 2,5 ml / 8
    hour / oral and Amoxicilin clavulanat 5 ml / 8hour / oral
    There was history of Mantoux test with negative result
    History of Vaccination MONTH YEARS
    Vaccine
    0 1 2 3 4 6 7 8 9 12 15 18 24 3 5 6 7 8

    Hep B V

    BCG

    DPT

    Hib

    OPV V

    IPV

    MR/MMR

    PCV

    Rotavirus

    Japanese
    Encephal
    itis

    Influenza

    Varicella

    Hepatitis
    A

    Tifoid

    Covid-19
    PHYSICAL EXAMINATION
    Vital Sign Anthropomethry
    General condition: Severely ill/severely Body weight : 7,5 kg
    wasted/GCS 15 (E4M6V5) Body Height: 67 cm
    Blood pressure: Head Circumference : 45 cm (44-49 cm)
    Heart Rate 112 times/min
    Nutritional status
    Temperature: 36,9 C
    Weight for age: in between -3 SD and -2 SD
    Respiration Rate: 25 times/min
    (underweight)
    SpO2: 99% via canula nasal
    Height for age: -3 SD (Short stature)
    Pain scale: 1 FLACC
    Weight for height: in between -1 SD and median
    (normal)
    HEAD
    CIRCUMFERENCE
    NORMOCEPHAL
    45 cm (44 cm – 49 cm)
    Weight for age: in between -3 SD
    and -2 SD (underweight)

    Height: 67 cm
    Weight: 7,5kg
    Height for age: -3 SD (Short
    stature)

    Height: 67 cm
    Weight: 7,5kg
    Weight for Length:
    in between -1 SD and median
    (normal)

    Height: 67 cm
    Weight: 7,5kg
    PHYSICAL EXAMINATION
    Pale, no jaundice Abdomen:
    No Lymphadenopathy Inspection: not distended
    Hyperemic Pharynx Auscultation: Peristalsis sound was normal
    Tonsil T2-T2 hyperemic Percussion: Tympanic
    Palpation: Hepar and Lien were not palpable
    Pulmo:
    Inspection: Symmetrical left and right Extremities:
    movement Warm acral, capillary refill time <3 seconds, no edema
    Palpation: vocal fremitus was symmetric
    Percussion: sonor on both of lung fields
    Auscultation: vesicular breath sounds,
    ronchi on both lungs no wheezing

    Cardiovascular
    Inspection: Ictus cordis was not seen
    Palpation: Thrill not palpable
    Percussion: Normal heart border
    Auscultation: Heart sounds I/II normal,
    regular rhythm, no murmur
    CENTOR SCORE
    Fever 1
    No Cough 0
    Lymphadenopathy 0
    Tonsil Swelling 1
    3-14 year of age 0
    Score 2
    TB SCORE
    Contact 0
    Fever 0
    Cough 1
    Lymphadenopathy 0
    Joint Swelling 0
    Thorax Xray not performed
    Nutritional Status 0
    Mantoux not performed
    Score 1 (without Thorax Xray and Mantoux test)
    Laboratory Finding
    Laboratory July, 04th 2023 (RSWS) Normal Value

    WBC 26.200 4.0 – 10.0/μL


    Hb 7,8 12.0 – 16.0 gr/dL
    MCV 58 80 -97 μm3
    MCH 17 26.5 - 33.5 Pg
    PLT 797.000 150.000 – 400.000/mm3

    % Neut 18.9 52,0-75,0

    % Lymph 65.7 20,0-40,0


    % Mono 12.7 2,00-8,00
    GDS 84 <200 mg/dl
    Ureum 14 10 - 50 mg/dl
    Creatinin 0.42 L < 1.3, P <1.1
    SGOT 53 < 38 u/l
    SGPT 20 < 41 u/l
    Albumin 4.3 3,5 -5,0 gr/dl
    Sodium 139 135-145
    Potassium 4.0 3,5-5,1
    Chloride 106 97-111

    Ferritine 39.38 13.00-400.00

    CRP 10.5 <5


    Laboratory Finding
    4/7/2023
    Urinalysis Normal value
    (WS Hospital)
    Color Yellow Yellow
    pH 4.5 4.5-8.0
    Bj 1.00 1.005-1.035
    Protein Negative Negative
    Glucose Negative Negative
    Bilirubine Negative Negative
    Urobilinogen Normal Normal
    Ketone Negative Negative
    Nitrite Negative Negative
    Blood Negative Negative
    Lekosit Negative Negative
    Leukocyte Sediment 2 <5
    Erythrocytes Sediment 0 <5
    Torak Sediment 0
    Crystal Sediment 0
    Epithelial Cells Sediment 0
    Others Sediment Bac = 3
    Assesment
    ● Community-acquired pneumonia
    ● Acute tonsillopharyngitis
    ● Short Stature
    ● Delayed imunization
    ● Anemia
    ● Leucocytosis
    ● Elevated transaminase enzyme
    ● Reactive thrombocytosis
    Working diagnosis
    ● Community-acquired pneumonia
    ● Acute tonsillopharyngitis
    ● Stunting
    ● Delayed imunization
    ● Iron deficiency anemia differential diagnosed with anemia of chronic
    disease
    ● Leucocytosis
    ● Elevated transaminase enzyme
    ● Reactive thrombocytosis
    Treatment
    • oxygenation via nasal cannula 1-2 liter /min • 1) Ceftriaxone 750 mg/24 hours/intravenous
    • Fluid requirement • 1) Gentamycin 20 mg/12 hours/intravenous
    Holiday segar – 20% respiratory distress • Paracetamol 100 mg/8 hours/intravena ( temperature
    >38 C)
    600 ml/24 hours
    • Nebulisation with NaCl 0,9% / 8 hours / inhalation
    Enteral: 5x100 = 500cc
    • N-acetylcysteine 40 mg / hours/ oral
    Parenteral: Infusion of dextrose 5% 5cc/hours/iv.
    Planning
     Thorax Xray
     Tuberculosis tracking (Mantoux test and gastric lavage examination)
     Sepsis workup (CRP, Procalsitonin, peripheral blood semar, Rasio IT, Culture of
    Blood, Urine)
     Consult to nutrition and metabolic disease division
     Consult to Hematology Oncology division
    THANK YOU

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